‘Choosing Wisely’: How much low-value care is preventable?

Choosing Wisely Campaign: Valuable For Providers Who Knew About It, But Awareness Remained Constant, 2014–17

By Carrie H. Colla and Alexander J. Mainor
Health Affairs, October 24, 2017


Together with physician specialty societies, the Choosing Wisely® campaign has codified recommendations of which health care services’ use should be questioned and discussed with patients. The ABIM Foundation administered surveys in 2014 and 2017 to examine physicians’ attitudes toward and awareness of the use of low-value care. The surveys included questions on the factors driving that use, physicians’ comfort in having conversations with patients about that use, and physicians’ exposure to the Choosing Wisely campaign. Despite continued publicity and physician outreach efforts, there were no significant changes between 2014 and 2017 in awareness of the campaign among physicians (awareness increased from 21 percent to 25 percent) or physician-reported difficulty in talking to patients about avoiding a low-value service (42 percent reported that such conversations had gotten harder in 2014, and 46 percent did so in 2017). Barriers to the adoption of recommendations included malpractice concerns, patient demand and satisfaction, and physicians’ desire for more information to reduce uncertainty. Multifaceted interventions that reinforce guidelines through personalized education, follow-up, and feedback, as well as aligned financial incentives, should be pursued to reduce the use of low-value services.

From the Introduction

Low-value care — care that provides little or no benefit to patients given costs, patients’ preferences, and available alternatives — is widespread in the United States. It is commonly estimated that up to 30 percent of care is waste, which contributes substantially to costs. Since its founding in 2012, the ABIM Foundation’s Choosing Wisely® campaign has sought to address the overuse of care by providing physicians and patients with information and training on potentially low-value services. While Choosing Wisely services vary widely in their potential impact on care and spending, they are a starting point in the conversation between patients and providers about low-value care.

Most physicians familiar with the campaign believe that it is valuable. However, it has yet to make a large difference in physicians’ or patients’ behavior.

Drivers of the use of low-value care

Physicians were asked to identify drivers of low-value care use, regardless of whether they thought the drivers were “major” or “minor” contributors to the use of that care. The most common reasons identified in the 2017 survey for ordering an unnecessary test or procedure were physicians’ malpractice concerns (87 percent), physicians’ desire for more information to reduce uncertainty (84 percent), and “just to be safe” (78 percent). On average, respondents identified five distinct reasons for the use of unnecessary care. Notably, all of these reasons increased in frequency from 2014 to 2017. The increases were significant in the case of not enough time to spend with patients, malpractice concerns, keeping patients happy, having access to new technology in the practice, feeling that patients should make the final decision, fee-for-service payment, and the physician wanting more information for reassurance.

From the Discussion

The estimates of awareness of the Choosing Wisely campaign in this survey are considerably lower than other estimates. Primary care providers have shown greater awareness of the campaign than specialists. Reports of the following barriers to reducing the use of low-value care in other research have been consistent with our findings: malpractice concerns and patient demand for services, concern about missing a serious diagnosis, community standards of care, lack of time to engage patients in shared decision making, the number of tests and treatments recommended by specialists, the proliferation of clinical performance measures with uncertain links to quality of care, and financial incentives.

Little empirical evidence has been found to support two commonly identified barriers to reducing the use of low-value care: demands from patients and physicians’ fear of malpractice liability. The demand for inappropriate services occurred in fewer than 1 percent of patient-clinician encounters in cancer care. This “myth of the demanding patient” — the idea that eager patients, rather than physicians, are driving the proliferation of unnecessary tests and procedures — risks leading to an underestimate of the impact of physicians’ choices on the provision of low-value care.

Physicians’ fear of malpractice liability is also commonly identified as a major contributor to the use of low-value care. However, empirical research has found that “defensive medicine” contributes roughly 3 percent to overall health care spending and that physicians do not change how they practice in response to changes in malpractice liability.



By Don McCanne, M.D.

It is often stated that 30 percent of health care could be eliminated without impairing medical outcomes. An effort to reduce low-value care - sometimes referred to as “medical waste” - is what the Choosing Wisely Campaign is all about. Specific presumed low-value services were selected and widely publicized as services that could be sharply reduced in volume and thus reduce our excess spending on health care.

Although this seems like a good idea, the program has been quite ineffective. Use of these services has been driven primarily by physicians rather than patients (“myth of the demanding patient”). Although physicians frequently claim that the purpose is to reduce the risk of malpractice liability, much of it is to reduce uncertainty or “just to be safe.”

Everyone would agree that care that is never of any value at all should be abandoned. But it is much more difficult to determine at which threshold care that is of low value should be abandoned. “Although the probability is low, this just might be an instance where this procedure would benefit my patient.” Besides, when recommendations for common serious disorders keep changing (mammography, PSA screening, etc.), how could we ever develop clearly consistent guidelines for management of the multitude of lesser disorders?

So the costs of that 30 percent of health care that is considered to be medical waste would be very difficult to recover, as the Choosing Wisely Campaign is demonstrating. That isn’t to say that we shouldn’t keep trying to reduce what might be unnecessary care, but we should not allow this effort to detract from proceeding with other reform that can recover a massive amount of waste - administrative waste, that is. A well designed single payer system would recover hundreds of billions of dollars by eliminating the administrative waste that is so prevalent in our dysfunctional health care financing system.

That is the point. Tremendous efforts are made to reduce medical waste, without much progress being made, whereas this effort has been used almost as an excuse to avoid a program that would greatly improve health care value - an improved Medicare for all. We should keep making efforts to refine medical management, but let’s move on immediately with enacting a financing system that would reap tremendous rewards.

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